Fillable City of San Dimas COVID-19 Emergency Small Business (City of San Dimas)

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City of San Dimas COVID-19 Emergency Small Business (City of San Dimas)

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  • 101 other fields

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File type: PDF

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City of San Dimas
COVID-19 Emergency Small Business Grant Program
Microen
terprise Assistance Self-Certification – Form A
To be eligible, the business must have:
• Five or fewer employees including the owner
• Business owner must have a household income at or below 80% of the Area Median Income
The program will collect income and employee information as of now, not as it was prior to the COVID-
19 pandemic. For example, the business may have had six employees, but laid off 3 and now may qualify
as a microenterprise as long as the owner’s income is below 80% AMI at this time.
Legal business Information:
Name:
Address:
Number of Employees – Full-time: Part-time:
Business Owner Contact & Household Information:
Name: Title:
Email: Phone:
Home Address:
Number of Persons in Household: Annual Household Income:
NOTE: To Qualify, the business owner must have a household income at or below 80% of the area
median income. That income level is listed in the chart below, based on the household size.
Emergen
cy Rental Assistance Household Income Limits
Number of
Persons
1 2 3 4 5 6 7
Moderate
Income Level
$63,100 $72,100 $81,100 $90,100 $97,350 $104,550 $111,750
I certif
y that this information is complete and accurate. I agree to provide, upon request, documentation
on all income sources to the City of San Dimas Small Business Grant Program Administrator.
________________
_____________ ________________________________
Business Owner Signature Date
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signature
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City of San Dimas
COVID-19 Emergency Small Business Grant Program
Microenterprise Assistance Self-Certification – Form A-1
INSTRUCTIONS: This is a written statement documenting the annual income, the number of
beneficiary members in the family or household, and relevant characteristics of each member
for the purposes of income determination.
To complete the statement, fill in the blank fields below using information from the attached
Individual Annual Income Self-Certification Form complete and signed by EACH HOUSEHOLD
MEMBER AGE 18 and OLDER except full-time students. The applicant head of household(s)
must then sign this statement to certify that the information is complete and accurate and the
source documentation will be provided upon request.
Applicant:
Address:
City: San Dimas
Telephone:
State: CA
Zip Code: 91773
Household Member Income Information:
Please Print: Please Check the Box that Applies to the Individual.
Name:
Total Annual Income:
˂15
HH = Head of Household; CH = Co-Head of Household; DIS = Person with disabilities; S≥18 = Full-time student age
18 or over; ˂18 = Child under the age of 18 year; ˂15 = Minor under the age of 15 years
Total Annual gross income (total of all numbers) = $ __________________________
I certify that this information is complete and accurate. I agree to provide, upon request, documentation on all
income sources to the City of San Dimas Emergency Small Business Grant Program Administrator.
HEAD OF HOUSEHOLD
Signatures
Printed Name
Date
CO-HEAD of HOUSEHOLD
Signatures
Printed Name
Date
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18 ,
Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for
knowingly and willingly making a false statement to a department of the United States Government.
CITY OF SAN DIMAS – COVID-19 Emergency Small Business Grant Program
INDIVIDUAL ANNUAL INCOME SELF-CERTIFICATION – Form A-2
Household Member (Print Name): _____________________________________
INSTRUCTIONS: To complete this statement, fill in the blank fields below using information from the attached
individual Annual Income Self-Certification Form complete and signed by EACH HOUSEHOLD MEMBER AGE 18 OR
OLDER except full-time students. The household member must then sign this statement to certify that the
information is complete and accurate, and that source documentation will be provided upon request.
Source of Income
Annual Income in Dollars
Salary
Self-Employed Profits
Social Security (SS)
Supplemental Security Income (SSI)
Social Security Disability (SSD)
California Work Opportunity and Responsibility for Kids (CALWORKs)
Temporary Assistance for Needy Families (TANF)
Pension
Alimony
Child Support
Unemployment Insurance
Interest from Bank Accounts and Cash Funds
Rental Property Income
Other Income Not Shown Above
Sources:
Total Gross Annual Income:
Check here if you are a HOUSEHOLD MEMBER AGE 18 OR OLDER with no income and certify by signing below.
I certify that this information is complete and accurate. I agree to provide, upon request, documentation on all income sources
to the City of San Dimas Emergency Small Business Grant Program Administrator.
Signature
Printed Name
Date
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title18,
Section 1001 of the U.S. Code States that a person is guilty of a felony and assistance can be terminated for
knowingly and willingly making a false or fraudulent statement to a department of the United States Government.
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City of San Dimas COVID-19 Emergency Small Business (City of San Dimas)

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Completed 24 January 2021

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